摘要
目的调查上海市医院的病案信息化管理情况,了解当前上海市医院在病案的信息化方面的管理现状,发现其中存在的问题,为进一步加强上海医院病案信息化管理提出相应建议。方法对上海69家医院进行现场问卷调查。调查问卷的内容包括医院病案库存和保存情况、信息系统管理和利用情况等。结果收回问卷69份,调查的医院病案库存总量为1623.27万份;59家医院(85.51%)已建立门急诊挂号系统,55家医院(79.71%)建有门急诊划价收费系统,54家医院(78.26%)建有门急诊药房管理系统,54家医院(78.26%)建有药库管理系统;46家医院(66.67%)建有电子病案系统,60家医院(86.96%)建有病案室病案管理系统,17家医院(24.64%)还建有专门的病案翻拍及检索管理系统;33家医院(47.83%)已通过医院计算机信息网络系统安全检测,36家医院(52.17%)未获得相关检测及证书;25家医院(36.23%)建有电子阅览室,44家医院(63.77%)未建立电子阅览室;12家医院(17.39%)对过去的出院病案进行微缩翻拍,16家医院(23.19%)对过去的出院病案进行数码翻拍。结论当前病案管理存在信息系统开发功能不完善和病案信息交流封闭等问题,应建立并完善"电子病案系统",同时推广和应用电子病案。
Objective To investigate the informatization management situation of medical records in Shanghai,understand the current management status of medical records in hospital of Shanghai, found out the problems and put forward relevant advice for further strengthening the informatization management situation of medical records.Methods To conduct questionnaire survey on 69 hospitals of Shanghai, the content included hospital medical record inventory and save, information system management and the utilization situation. Results 69 questionnaires were collected, the total inventory of the hospital medical record was 16232700, 59 hospitals（85.51%） had established emergency registration system, 55 hospitals（79.71%） with this price charge system, 54（78.26%）have built this hospital pharmacy management system, 54 hospitals（78.26%） with pharmacy management system; For professional management of hospital medical record, many hospitals are seriously, 46 hospitals（66.67%） with electronic medical record system, 60 hospitals has built record room medical record management system（86.96%）,17 hospitals（24.64%） also has a special medical record remake and retrieval management system; 33 hospitals（47.83%） has passed the hospital computer information network system security testing, 36 hospitals（52.17%）did not get the test and certificate; 25 hospitals（36.23%） with electronic reading-room, 44 hospitals（63.77%） of the electronic reading room has not been established; 12 hospitals（17.39%） out of the hospital medical record of the past miniature remake, 16 hospitals（23.19%） out of the hospital medical record of the past digital remake.Conclusions The medical record management existing problems included incomplete information system development function and closed medical record information exchanges, we should establish and improve the electronic medical record system, promote and apply of electronic medical record at the same time.
出处
《中国病案》
2016年第1期39-41,共3页
Chinese Medical Record
关键词
病案
管理
信息化
Medical record
Management
Informatization
